Across the country, LeadingAge members are experiencing increasing difficulty in staffing their organizations with qualified workers capable of delivering high-quality care to residents and clients.

“You have to chip away at it, because even small gains can have meaningful impacts,” says Frederick Morgeson, Ph.D., the Eli Broad professor of Management at Michigan State University in East Lansing, an expert in human resource management and organizational behavior. “It is a huge challenge and to tackle it requires a multifaceted approach.”

A LeadingAge workforce survey found that 83.5% of members called “not having a pipeline of workers” their most significant barrier. In Wisconsin, a LeadingAge membership survey determined workforce issues were the top 3 concerns. A 2016 report found that nearly half of Wisconsin members responding had no applicants for vacant caregiver positions, with unskilled entry-level jobs in the state paying significantly more than personal caregiver positions.

“With the unemployment rate low, there is a tremendous competition for workers,” says Jim Williams, director of member enrichment at LeadingAge Wisconsin in Madison.

Jenna Kellerman, director of workforce solutions at LeadingAge Minnesota in St. Paul, reports that positions can remain unfilled for months due to a lack of applicants. A LeadingAge Minnesota workforce data paper reported that 70.1% of respondents indicate no applicants apply for the open positions.

Additionally, 75.8% of Minnesota respondents report competition from other employers as a reason for vacant positions. Other employers, such as Arctic Cat, pay a good wage and have regular hours. Yet even acute care providers pay significantly more than long-term care, $6.06 more per hour for a registered nursing assistant and $17.94 more per hour for a registered nurse. To make ends meet, Kellerman says nursing assistants in long-term care often work more than one job.

“Many caregivers are living in poverty,” Kellerman says. “Oftentimes, it’s a generational poverty.”

Positions can remain unfilled for months due to a lack of applicants. A LeadingAge Minnesota workforce data paper reported that 70.1% of respondents indicate no applicants apply for the open positions.

“You have tremendous churn, partly because they are not the greatest jobs,” Morgeson says. “The care you provide includes a lot of things that are not pleasant.”

What’s Causing the Pipeline Problem?

A combination of factors contributes to the problem, and experts do not expect recruitment to become easier in the future.

“This is a perfect alignment of the features of the job and features of the environment,” Morgeson says.

The country’s population is getting older. By 2050, the number of adults age 65 or older is expected to reach 88 million, according to the LeadingAge report. Those people are more likely to need services.

“As the aging cohort grows, the working cohort is shrinking,” says Kellerman, who explains that currently the ratio of workers to people age 85 and older, those most likely to use long-term care services, is 15 to 1. By 2035, it will be 8 to 1.

“We are feeling the shrinking workforce now, but we know it is going to get nearly twice as challenging,” Kellerman says.

The rebound of the economy and an increased demand for employees contributes to the pipeline problem, Williams adds.

By 2030, the country will need 2.5 million long-term services workers, according to the LeadingAge report. The Bureau of Labor statistics reports by 2024, many of the top positions for job growth are in health care. The United States will add 458,100 personal care aides, 439,300 RNs, 348,400 home health aides, 260,000 nursing assistants and 117,300 licensed practical nurses.

Image of the field and lack of awareness of the opportunities in it are factors that deter potential employees from working in long-term care, says Dana Weaver, chief operating officer of LeadingAge Kansas in Topeka.

“Nurses do not want to go into long-term care, because they are viewed as nurses who cannot hack it in the acute world,” Weaver reports.

Weaver says that Kansas being a rural state exacerbates the pipeline issue, since many young people leave smaller communities. Few community colleges exist in these areas to train aides or nurses. Yet even in the Kansas City area, people have a hard time getting aide training, because the community college requires nursing students to become aides first, clogging the pipeline for those people who want to become aides.

Another problem unique to Kansas is that homes receiving an “Immediate Jeopardy” deficiency are banned from hosting a nurses’ aide course. She reports 95% of the homes have a ban on training.

“There are so many prongs to this,” Weaver says.

How to Solve the Pipeline Problems

Since many LeadingAge members report available talent is heading to other employers that pay more, increasing long-term care wages could be a potential lever, Morgeson says.

“We’d love to do that,” says Kellerman, adding that private pay residents can only afford so much, and government reimbursement is too low to allow providers much flexibility in wages.

“Rates do not support large increases or even modest increases in staff wages,” Williams says. “As providers, we realize the value of caregivers.”

LeadingAge Wisconsin was successful, using the data it and other organizations gathered, in convincing the legislature to increase the nursing home Medicaid rate by 2%.

LeadingAge Kansas has joined with the Kansas Health Institute, a research body, to evaluate wage disparities between acute and long-term care. So far, it has found RNs and CNAs are underpaid in long-term care, but LPNs are overpaid.

“While pay is important, it’s not always at the top of the list,” Williams says. “Recognition and being treated with respect and being solicited for opinions are as [important] if not more important than pay.”

The work environment is something providers have control over, Morgeson says. He suggests asking people what they want and what can be done to make them stay.

“You won’t be able to do everything, but what is realistic,” he adds. “It’s a communication and openness thing. You have to trust folks. When endowed with trust, they will often reciprocate with trust.”

To change the environment, you have to think creatively if there isn’t the money, Morgeson recommends.

“If there are negative tasks, maybe there are opportunities to distribute in a different way or build a more team or socially positive environment,” Morgeson suggests. “It gives people others to talk with. People like working where they have close friendships.”

Stress management education and modification of the duties could make the jobs more desirable, he adds.

“You could give people more freedom and responsibility in doing the activities,” Morgeson recommends.

Some members are trying to improve the work environment. Quality of leadership makes a difference, Morgeson says.

In Minnesota, Kellerman says, LeadingAge offers tools for leaders in having difficult conversations, recognizing staff and making work fun. LeadingAge Wisconsin has offered leadership training at its conferences.

Currently, in Wisconsin, 84% of providers are relying on overtime, double shifts and other strategies to fill the hours. That can lead to burnout and poorer outcomes.

“Opportunities for errors and employee injury goes up,” Williams says. “Sometimes, overtime is the only strategy you have.”

Creating career awareness and the rewards of working in long-term care is another option. Morgeson suggests leveraging the fact that even in the lowest-level job, an employee is doing a social good and positively affecting someone else.

“You are doing something every day that is making a difference in someone’s life,” Kellerman says. “Younger generations want meaningful work, and that is something we can capitalize on.”

Williams, at LeadingAge Wisconsin, also reports working on raising awareness of the rewards of working in the field.

“Many people want work with a sense of purpose,” Williams says. “It’s helping them understand the jobs out there and getting training opportunities.”

“You are doing something every day that is making a difference in someone’s life. Younger generations want meaningful work, and that is something we can capitalize on.”

Developing career opportunities may entice some people to the field, especially with tuition reimbursement. Kellerman said in aging services, people can often move up the ranks more quickly than in other fields. Minnesota created an apprenticeship program for nursing assistants to become health support specialists, elevating the professional caregiving world.

“It’s a way to increase wages and to have staff more educated, empowered and better caregivers,” Kellerman explains.

Morgeson suggests working with high schools and community colleges to build a steady supply of people.

Weaver is meeting with community colleges and technical schools across the state to educate them about long-term care opportunities.

“I’m trying to raise the image and let them know this is a major employer in smaller communities,” Weaver says. “That has been pretty successful. Some members are getting calls to be on advisory groups. And we have been invited into meetings to discuss improving the pipeline.”

Looking further ahead, Kellerman believes the field will need to look toward technology for solutions, because there just will not be enough people.

“We will have to flip this sector upside down to make it work in 20 years,” Kellerman says. “It’s more than recruitment and retention. We have to look at how we are delivering care.”